Citizens' Police Academy Application

The 2013 Citizens' Police Academy is now accepting applications! The class will be held on Tuesday's from 6pm-9pm, June 18th, 25th, July 2nd, 9th, 16th and 23rd. Please fill out the information below and someone will contact you about your application. A limited number of spots are available so don't wait!

Personal
Data: All
fields in bold are required.

Last Name:

MI:

First Name:

SSN:

(No spaces or dashes)

Driver's License #:

Exp. Date:

(8/1/1985)

Date
of Birth:

(8/1/1985)

Address:

City:

State:

Zip
Code:

(65201) (5-digits)

Home Phone:Please
include area code.

(5738747104) (No
spaces or dashes)

Work Phone:Please
include area code.

(5738747104) (No
spaces or dashes)

E-Mail:

Have you ever
been arrested?
Yes
No

If Yes,
Describe:

Emergency
Contact:

Person
to notify in case of an emergency:

Phone:Please include area
code.

(5738747104) (No
spaces or dashes)

References: List
(3) references excluding relatives:

Name:

Occupation:

Address:

City:

State:

Zip
Code:

(65201) (5-digits)

Phone:Please
include area code.

(5738747104) (No
spaces or dashes)

Name:

Occupation:

Address:

City:

State:

Zip
Code:

(65201) (5-digits)

Phone:Please
include area code.

(5738747104) (No
spaces or dashes)

Name:

Occupation:

Address:

City:

State:

Zip
Code:

(65201) (5-digits)

Phone:Please
include area code.

(5738747104) (No
spaces or dashes)

Describe
briefly why you are interested in attending
the Citizens' Police Academy: